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Gwen - Neurology > Stroke and TIA - Acute investigation and Management > Flashcards

Stroke and TIA - Acute investigation and Management Flashcards

1
Q

Investigations of stroke

A

Blood tests

  • Us and Es

Risk factors for atheroma

  • BP
  • Blood tests
    • Glucose
    • Cholesterol
    • Thyroid function (AF risk)
    • LFT (alcohol consumption)

Sources Embolism

  • Heart
    • ECG
    • Echo (cardiac thrombus, valvular disease)
    • Blood cultures
    • 24hr tape
  • Neck and intracranial vessels
    • Carotid doppler
    • Angiogram/MRI

Causes of tendancy to thrombosis

  • Blood tests
    • FBC
    • Thrombophillia screen (protein C+S, lupus anticoag)
    • Sickle cell screen

Causes of inflammatory vascular disease

  • Blood tests
    • ESR
    • Syphillis serology
    • Temporal art biopsy

Bold = all stroke patients

Imaging

  • CT to differentiate between infarct and haemorrhage
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2
Q

Difference beetween infarct and haemorrhage on CT?

A

Dark = infarction

White = haemorrhage

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3
Q

Key questions to ask yourself when assessing a stroke

A

1. Is it a stroke

2. What kind of stroke

CT/MRI
History and exam

3. Why did the stroke occur

Ix used depends on the clinical picture

Eg:
Possible cardiac source? Full cardiac work up
Small stroke anterior circulation? Carotid doppler
Haemorrhagic? Clotting profile, cerebral angiography (AV malformations)

4. Worsening factors

Systemic metabolic disturbances
Esp hypoxia and hyperglycaemia will affect function of ischaemic brain and worsen stroke

Appropriate fluid balance/monitor Us and Es

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4
Q

If someone presented with clinical features suggestive of a stroke, what would you do?

A
  • ABCDE
  • History - Exact onset, changes/progression, Risk factors
  • Examination - full neuro exam, systemic and risk fcator exam
  • CT - within 1 hour presentation
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5
Q

When would you treat hypertension in someone presenting with a stroke?

A
  • Hypertensive emergency (encephalopathy/aortic dissection)
  • If thrombolysis is being considered
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6
Q

How long after presentation with symptos of a stroke should someone get a CT head?

A

Within 1 hour

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7
Q

When is CT/MRI within the first hour of presentation with stroke sypmtoms essential?

A
  • If thrombolysis considered
  • High risk of haemorrhage
  • Unusual presentation - fluctuating consciousness
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8
Q

What is the most sensitive imaging modality for detecting acute infarction?

A

Diffusion-weighted MRI

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9
Q

What happens at a cellular level when cerebral infarction occurs?

A

Hypoxic damage:

  • Na+/K+ pump Fails -> Na+ accumulates in the cell -> osmotic shift into cell -> cellular swelling
    • Cells in the immediate area around the infarct die very quickly, as they swell and burst. Cells in “penumbra” are relatively less oematous, and can be “saved”
  • Excitotoxicity - Damage as a result of prolonged depolarisation of cells in affected area
    • Results in failure of AMPA and NMDA receptors - allows excessive calcium into the cell. This causes release of free radicals, production of cytokines, and direct apoptotic effects in the penumbra
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10
Q

What specific things might you look for on examination in someone presenting with features of a stroke?

A
  • Thorough, full neruo exam - clinical diagnosis and lesion localisation
  • Pulse (AF)
  • Heart sounds (valve disorders)
  • Carotid Bruit
  • Signs of PVD
  • Bruising/Bleeding
  • Xanthalasma/Xanthoma/Corneal arcus
  • Tar Staining
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11
Q

When would you consider thromblysis in someone presented with a stroke?

A

Once haemorrhage has been excluded as cause, and within 4.5 hour window of onset (benefits outweigh risks within this window)

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12
Q

Within what time frame are the best results achieved using thrombolysis?

A

Within 90 minutes of onset

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13
Q

What thrombolytic agent is most commonly used in stroke management?

A

Alteplase

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14
Q

What are contraindications to thrombolysis in a stroke?

A

Look them up - Impossible to remember all of them!!! - think of categories of contraindications

  • Stroke related
  • Neurological
  • Bleeding tendency
  • Trauma
  • Medical problems
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15
Q

What are stroke related contraindications to thrombolysis

A
  • Rapidy improving symptoms
  • Ischaemia of >1/3 MCA territory
  • Symptoms suggestive of SAH
  • Seizure at start of stroke
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16
Q

What are neurological contraindications to thrombolysis?

A

History of intracrnal bleed, aneurysm or neoplasma

Spinal or cranial surgery/injury

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17
Q

What bleeding tendency risk factors are contraindicaitons to thrombolysis?

A
  • Significant bleeding disorder
  • Therapeutic anticoagulation - LMWH, DOACs, Warfarin
  • Iron deficiency anaemia
  • Thrombocytopenia
  • Advanced liver disease
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18
Q

What are trauma related contraindications to thrombolysis in stroke?

A
  • Significant head injury <3 months
  • Major surgery/delivery/external heart massage <2 weeks
  • Puncture of non-compressible blood vessel <2 weeks
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19
Q

What medical problems are contraindications for thrombolysis in stroke?

A
  • SBP > 180/DBP >110
  • Active internal bleeding
  • Aortic aneurysm
  • Bacterial endocarditis/pericarditis
  • Acute pancreatitis
  • Haemorrhagic retinopathy
  • Oesophageal varices
  • Ulceratie GI disease <3 months
  • GI/GU haemorrhage < 3 weeks
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20
Q

If thrombolysis was contraindicated, what treatment would you start someone on for acute treatment of a stroke?

A

Aspirin PO/PR OD for 2 weeks

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21
Q

Why does diffusion weighted MRI detect early abnormalities seen in infarction better than normal MRI or CT?

A

This type of MRI exploits the fact that damaged cells fill with water – and thus contain more water than normal cells in the early stages of damage.

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22
Q

What intial investigations would you consider doing in someone presenting with a stroke?

A
  • CT/MRI - within 1 hour
  • MRI angiography
  • ECG
  • CXR
  • Bloods - ESR, FBC, clotting screen, glucose, Lipids/cholesterol
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23
Q

Why might you do an ESR on someone presenting with features of a stroke?

A

If with headache and tender scalp - Giant cell arteritis

24
Q

Why might you do FBC or clotting in someone presenting with a stroke?

A

Look for evidence of clotting/bleeding disorders - thrombocytopenia, polycythaemia

25
What would you want to prioritise in your ABCDE assessment in someone presenting with a stroke?
* **Maintain airway** * **Prevent hypoxia** * **Hydrate** * **Treat fever / source of fever** – this can help to limit the extent of damage * **Treat hypo / hyperglycaemia**
26
What dose of aspirin would you give someone if thrombolysis was contraindicated?
300 mg
27
How long would you put someone on aspirin treatment for following a stroke?
2 weeks
28
Primary management of ischemic stroke?
Thombolysis within 4 hours - alteplase, consider contraindications. Aspirin (300mg) daily - given as soon as possible after onset of stroke symptoms once brain imaging has excluded haemorrhage Hypertension managment - only lowered in acute stage where there are liekly to be complications (hyptensive encephalopathy, HF or aortic dissection)
29
Secondary stroke management of ischaemic stroke
1. Anti-hypertensives (ACEI) 2. Antiplatelets (Aspirin + Dipyridamole **or** Clopidogrel) 3. Statins 4. Warfarin for AF
30
What medication would you start someone on following 2 weeks of aspirin treatment?
* **Clopidogrel long term -** monotherapy * **Consider Warfarin if AF the cause** * **Statin** - 48 hours after stroke
31
What dose of clopidogrel would you give someone as long-term prophylaxis?
75 mg OD
32
What could you give someone if they did not tolerate clopidogrel for post-stroke prophylaxis?
Slow-release dipyridamole
33
What is the definition of a transient ischaemic attack?
A brief episode of neurological dysfunction due to ***_temporary focal cerebral_*** or ***_retinal ischaemia without infarction_***, e.g. a weak limb, aphasia or loss of vision, usually lasting seconds or minutes with complete recovery. TIAs may herald a stroke. The arbitrary time of \<24 hours is no longer used.
34
If someone presented with a TIA with amaurosis fugax, where might the occlusion be taking place?
Retinal artery occlusion
35
What are causes of TIA?
* **Atherothromboembolism** * **Cardioembolism** - Mural thrombus, AF, Valve disease * **Hyperviscosity** - polycythaemia, sickle-cell, myeloma * **Vasculitis** - cranial arteritis, SLE, PAN
36
What are features of an anterior circulation TIA?
Carotid system * **Amaurosis fugax** * **Aphasia** * **Hemiparesis** * **Hemisensory loss** * **Hemianopic visual loss**
37
What are features of a posterior circulation TIA?
* **Diplopia, vertigo, vomiting** * **Choking and dysarthria** * **Ataxia** * **Hemisensory loss** * **Hemianopic visual loss** * **Bilateral visual loss** * **Tetraparesis** * **Loss of consciousness (rare)** * **Transient global amnesia (possibly)**
38
If, on examination of someone presenting with signs of a TIA, you found there to be central retinal artery occlusion, where might this suggest there is stenosis in the carotid system?
Internal carotid artery stenosis
39
What differentials would you want to consider in someone presenting with features of a TIA?
* **Hypoglycaemia** * **Migraine aura** * **Focal epilepsy** * **Hyperventilation** * **REtinal bleeds** * **Malignant hypertension** * **MS** * **Intracrnaial tumours** * **Peripheral neuropathy** * **Phaeochromocytoma** * **Somatization**
40
What investigations would you consider doing in someone with a suspected TIA?
* **Bloods** - FBC, U+E's, Glucose, Lipids * **CXR** * **ECG** * **Carotid doppler +/- angio** * **CT/Diffusion weight MRI** * **ECHO**
41
How would you manage someone with a TIA?
* **Control risk factors** - BP, DM, Hyperlipidaemia, Smoking * **Antiplatelet therapy** - Aspirin (300mg) for 2 weeks, then clopidogrel (75mg) long-term * **Consider anticoagulation** - AF * **Consider carotid endartectomy** - within 2 weeks of presentation if \>70% stenosis and no contrindiations
42
How long after a TIA are individuals not allowed to drive?
1 month - Need to inform DVLA if stll symptomatic after 4 weeks or HGV driver
43
What scoring system could you use to stratify those who have had a TIA who might be at higher risk of stroke in the future?
ABCD2 score - score \>/=4 indicates high risk of early stroke - assess by specialist in 24 hours
44
Contraindications to thrombolysis
AGAINST Aortic dissection GI Bleeding - internal bleeding Allergic reaction previously Iatrogenic - recent surgery Neurological - cerebral enoplasm, recent haemorrhage stroke (on CT), low GCS Severe hypertension (\>180/90mmHg) Trauma - including CRP So - NO MOTOR DEFICIT, SYMPTOM ONSET \>3HOURS\< IMPARIED CONSCIOUSNESS, COAGULOPATHY (INR\>1.8)
45
How does alteplase work
Converts plasminogen to plasmin which degrades fibrin to FDP Ie decreaese platelet aggregation
46
Potential surgical management of stroke
Carotid endarterectomy - for those with \>70% stenosis (surgical excision of atheromatous segments) Large intracranial haematoma (surgical excision) Large cerebellar stroke (brain stem compression)
47
Secondary stroke managmenet: ASPIRIN: SE, Cautions, Contraindications CLOPIDOGREL: When, SE
Aspirin: * 300mg 2 weeks * NSAIDs can antagonise effects so withhold during 2 weeks of aspiring use * Inhibits thromboxane 2 * SE: GI irritation/bleed * Cautions - asthma, uncontrolled hypertension, previous peptic ulcer * Contraindications - Known allergies, GI ulcers, pregnant Clopidogrel * 2 weeks postischaemic (after aspirin) or post TIA * SE: Dyspepsia, abdo pain * PPIs could reduce efficacy
48
Secondary stroke management: STATINS SE, Monitoring, Interactions, whats first line
SE: Myopathy, GI effect, altered LFTs Monitoring: LFTs measured prior to therapy after 12 weeks and then annually, non fasting total cholesterol, TFTs, HbA1C Interactions: Antiarrhythmitics, antibiotics (macrolides) - stop statin for period for period of antibiotic use, anticoagulants, graperuit juice First line: Atorvostatin 80mg
49
Secondary stroke management: Antihypertensives Common used? SE Monitoring
Perindopril and indapamide SE: Dry cough, dizziness/first dose hyptension, AKI, angioedma, hyperkalaemia Monitoring: Us and Es (renal function, potassium)
50
Secondary strok managmenet: Anticoagulants When used? When witheld?
When used - ischaemic patients with AF Aspirin 3 days then start anticoagulant Eg Endoxaban
51
What medication would you expect someone to be on day 2 post stroke?
Aspirin Artorvostatin
52
What medication would you expect someone to be on 16 days post stroke?
Clopidogrel Atorvostatin Perindopril Indapamide Endoxaban in patinets with AF
53
Carotid symptoms TIA
(POSTERIOR) Amarosis fugax Aphasia Hemiparesis Hemisensory loss Hemianopia visual loss
54
Vertebro-basillar teritory symptoms
(ANTERIOR) Diplopia Vertigo Vomiting Dysarthria Choking Ataxia Hemisensory loss Visual loss Paresis
55
Signs of TIA
Carotid bruit Hypertension AF Heart murmur from vascular disease Fundoscopy during TIA - retinal artery emboli
56
DDx TIA
Migraine Partial seizure Transient global amnesia Intracranial lesions Metabolic hypoglycaemia Peripheral nerve lesions - in intermittent sensory loss
57
Management of TIA
Aspirin 300mg + Dipyridamole (Clopidogrel if intolerant) - aspirin given 2 weeks after for life post TIA Warfarin (AF) Carotid endartectomy Secondary prevention - control of risk factors

Gwen - Neurology (38 decks)

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